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Tuberculosis as a deficiency disease
108
'l'UBERCLE
LDecember, 1922
T UB ERCUIJOSIS AS A DEFICIENCY DISEASE.
By V. F .
SO OT H I L L ,
M.D ., D.P.H.
Deputy M ed ic al Officer of Health , Li ford,
'I'uberculosis is usually combated by fresh air and extra food, such as ,eggs, milk, butter, and cod liver oil. These are all substances rich in the fat- soluble or anti-rachitic factor, whatever that may be. Is it the comparative abundance of this factor which determines the success or failure of our resistance to the tubercle bacillus ?l The tubercle bacillus is ver y widespread. In an individual the result of any infection depends on the size of the dose and the person's resistance. Is not the quality of the resistance the more important item in tuberculosis? The medical and nursing professions must all be heavily infected, and some make a more successful resistance than others, who do not appear to he especially exp osed to infection'. The children on any dairyman 's round probably all receive, on the average, the same number of tubercle bacilli, but some resi st better than others. The cost of ordinary milk does not vary inversely with its bacillary content, and children of the richer classes, who drink more milk than others, get less tuberculosis, even of the bovine variety. Further, is not the most important period-from the anti-tuberculosis point of view-for ensuring an adequate supply of this particular subst ance the period of ante-natal and post-natal development ? This would imply the necessity of a good supply to the providers of infant nourishment, namely, the pregnant and nursing mother, and the cow. The above is the per iod during which rickets is cau sed or avoided, and the prevalences of tuberculosis and rickets are closel y connected. It is possible that by avoiding rickets, even the "minor " forms in children, we shall be doing a great deal to eradicate tuberculosis in later life. The two conditions are always more marked in poverty-stricken areas and the fat-soluble factor is always expensive. Fat containing factor A was especially hard to get during the later years of the war, and during this time there was a recrudescence of tuberculosis, though this may have been merely the abnormal reawaking of latent disease due to harder work and bad conditions. We are told that the accessory food factors are necessary in only very small quantities. This may be the CHose with the others, but is it true of the fat-soluble factor'? Very small quantities may be sufficient to permit some growth and ordinary upkeep, but large quantities seem to be required for perfect growth, especially in a rapidly growing animal. Rickets, even in the gross form, is very common, and, in its" minor .. forms, is always with us. If, as seems almost certain, dental caries is largely due to this deficiency, how few avoid it. Of the tuberculous patients examined at a tuberculosis dispensary, many have SOIDe bone malformation, and if dental caries is accepted as a sign of deficiency, practically none are free, bearing in mind that teeth are obviously intended to last a lifetime. The bronchial and alimentary tracts are constantly involved in rickets, and often are the only tissues affected in the. min~r form s, the bronchitis of children being usually curable by cod-liver 011. • " The Accessor v Food Factor s," Medical Research Committee, Special Report!', No. 38.
December, 19221
TUBERCULOSIS AS A DEFICIENCY DISEASE
109
Can one imagine a condition more favourable to the entry of either alimentary or pulmonary tuberculosis than the sodden debilitated lining membranes of those two tracts, perhaps already infected with other organisms? Is not rickets the true pre-tuberculous state? Seeing that the calcification of some permanent teeth has begun before birth, dental caries and also tuberculosis may be largely preventable antenatally. Moreover, though the mother during pregnancy and lactation, or the child may be sufficiently supplied with the substance in question, it does not follow that they will be able to absorb it. Continued vomiting during pregnancy may have the harmful effects under discussion, on the infant. In the infant, an attack of gastro-enteritis may produce an inability to absorb, lasting perhaps for some time, and this may be sufficient to induce rickets. Gastro-enteritis is frequently the reason for the early weaning of a child, and this may help to account for the frequency of rickets in bottle-fed babies, apart from the quality of the food given afterwards. In a case where, for whatever reason, the usual supply of the vitarnine is only just enough, the vomiting of the pregnant mother or the attack of gastro-enteritis in the child may be sufficient to turn the scale and precipitate a slight attack of rickets in the child. With regard to the mother, the exploded, but still prevalent idea that green vegetables cause colic in the child, may cut off a very important source of supply. The fact, too, that women's teeth give way during pregnancy, as also at puberty, implies a demand for the vitamine at these times greater than the ordinary supply, and one may point to the fact that a quiescent or mildly active pulmonary tuberculosis often increases in activity about pregnancy. The common use of barley or oatmeal water for the dilution of milk for a bottle-fed baby may cause the undesirable presence of a carbohydrate mentioned by Mellanby as a contributory cause of rickets, apart from the possible over-dilution of the milk. There have been outcries against milk as the carrying agent of the bovine forms of tuberculosis, but is it not the lack of milk, with an abundant presence of the vitamine in question, rather than the ingestion of tuberculous milk, the factor ·wh ich determines the active infection of the individual? Every doctor has seen many children in whom tuberculosis has developed in spite of great care on the part of the mothers, who may have always used sterilised milk or always boiled all the milk used in the house. It would seem that the numbers of living tubercle bacilli taken by such non-resisting children are smaller than the numbers taken by many children who do not get the disease, and this lack of resistance may be due to the destruction of the vitamines in the early days, the substances being altered by heat as in the case of lard. In these cases there is often no lack of food or air at any time. Moreover, it seems possible to make this suggestion in practically all cases of pulmonary and alimentary tuberculosis. Arguments against this suggestion naturally present themselves. There are other agents of bovine tuberculosis besides milk, for instance butter and even cheese, but as a rule, at any rate among the poorer population one child probably takes as much tuberculous butter as another, with few individual exceptions, and therefore the question of individual resistance retains its importance. Indeed, the poorer classes, who suffer
110
TUBERCLE
[December, 1922
most severely from tuberculosis, probably do afford less butter than others. Again, milk so-called pasteurised, scalded, or boiled , is often ver y imperfectl y sterilised , but the number of living tubercle bacilli taken by the individual concerned is probably not actually increased by the process and the non-resisting cases develop symptoms. There are native races which have suffered severely from epidemics of tuberculosis following the introduction of an infectious person. Here the resistance was obviously low and the cause for this is generally held to be the lack of hereditary and acquired immunity. 'Wit hout denying this, it may be suggest ed that the vitamine-content of their various diets has not yet been worked out, as far as the writer knows. In this connection it must be remembered that the vegetable oils are remarkably deficient in the" fat-soluble factor," meat is very scarce with some races, and not all fish is well supplied. Further, in all races and at all times there are people who prefer a sweet and farinaceous to a meat and fat diet. With regard to immunity the fact is that the descendants of tuberculous families, who should have a high hereditary and acquired immunity, are very liable to develop symptoms. Without doubt, increased liability to repeated infection pla ys a very imp ortant part in this process , but is it sufficient? Sometimes the secondarily infected patient dies before the primary one, e.g., a mother with .. chronic bronchitis " infects her son, who dies of tuberculosis while the mother still lives. In this case, the son cannot have It larger infection than the original source of his disease, but his resistance is lower, in spite of the increased immunity he ought to have. The bacilli may have become more virulent after passage through another host, but that is not proved. The different immunities in various animals present some interesting problems. Why do not rabbits suffer severely from tuberculosis in the wild state, as they are very susceptible? They must at times be crowded together, but they can then always obtain adequate supplies of green food, rich in the fat soluble factor. Why are sheep immune from tuberculosis while pigs and cows suffer ? Sheep are often more crowded than cows or pigs but ha ve more natural food than cows, while pigs take considerable quantities of milk from which the fat-soluble factor has been removed. Do the cattle grazing in a semi-wild state abroad suffer from tuberculosis '1 One may here ask-will the modern extensive use of artificial cake for our cattle be beneficial to us or the reverse ? The amount of sterilised food taken in the last half century has increased very much. people eating far more tinned food than formerly and tuberculosis has not increased but decreased. At the same time it has not decreased as rapidly as was hoped and expected. In this CODn ection lllay be mentioned the fishermen of Norway. In the days of short journeys in open boats with much physical labour tuberculosis was rare. With the advent of the steamer, longer journeys and closed cabins, tuberculosis increased, largely owing possibly to those conditions; but that period also saw the wide introduction of preserved milk and other foods. Is this merely a coincidence ? The fact that tuberculosis is still so prevalent, in spite of its general decrease, suggests that someth ing further is required in addition t? the extremely valuable work already being done. There can be no desire to minimise this work and it is a pity that some efforts, such as the by-laws
December, 19:12 J
SANATORIUM TREATMENT
111
against spitting in railway carriages, are not more enforced by public opinion. These efforts, however, largely aim at the reduction of the infecting dose, prophylactic vaccination, even if of value, not being widely practised. It is suggested that future generations might be better protected through increasing individual resistance by an abundant supply of the "fatsoluble" factor to the developing child, before and after birth. This raises the important question of the milk supply, which is receiving considerable attention and, one may add, that of the encouragement of allotment workers. Should not our efforts be directed to the cleansing of our milk production plant and the improvement of the feeding of our cattle rather than to the tuberculin-testing of our herds? The production of milk, clean enough for young children and mothers to drink unsterilised as a general rule, will certainly be a slow and difficult process, but the eradication of tuberculin-reacting cows will be more so and more costly; moreover the latter course may have the bad effect of making milk scarcer and dearer. As things still are, one has to choose between sterilised or dried milk, with its probable lack of vitamines-even if some of these can be otherwise supplied-and unsterilised milk, with, too frequently, consequent gastro-enteritis. It may at present be the lesser evil, but will the increased use of sterilised milk and other patent infant foods, lacking apparently the fat-soluble or anti-rachitic factor, prevent a fall in the tuberculosis rate of later generations? There seems to be considerable evidence pointing to. this possibility and the question is worthy of serious consideration. ADDENDUM. Published work, only seen by the writer after this paper was written, has confirmed the suggestion that attention should be directed to the effect of various foodstuffs on the vitamine content of cow's milk. DUHATION OF SANATORIUM TREA'l'MENT. By RONALD CAMPBELL MACFIE, M.A., M.B., C.M., LL.D. ONE of the problems to be faced in the treatment of patients at private sanatoriums, is the matter of length of sojourn. When a patient arrives at a sanatorium, one of his first and most anxious questions is: "How long shall I have to stay?" To give a categorical answer to such a question is almost impossible. No specialist can say at first sight ~ow qui~kly a patient will respond to treatment, or at what date the disease WIll be arrested or cured; and if the doctor confess that he is no prophet he is liable to be considered a fool. Even when a fairly definite prognosis might be given there are difficulties in giving it. If the doctor knows it is going to be " a long job," and suggests that treatment must be continued for a year or two, he will probably lose the patient, or the patient will lose heart. H on the other hand, in order to cheat the patient, he intentionally minimises the time requisite, he lays himself open later to a charge of wrong prognosis, and sow~ seeds of re~rimination and. disappoi~t~en~. The best thing he can do lD most cases IS to refuse to gIve an oplDJOn, If he can persuade the patient and his friends to accept a refusal. The problem is further complicated by the fact that a patient's private doctor often persuades him to enter a sanatorium by a fraudulent promise
'l'UBERCLE
LDecember, 1922
T UB ERCUIJOSIS AS A DEFICIENCY DISEASE.
By V. F .
SO OT H I L L ,
M.D ., D.P.H.
Deputy M ed ic al Officer of Health , Li ford,
'I'uberculosis is usually combated by fresh air and extra food, such as ,eggs, milk, butter, and cod liver oil. These are all substances rich in the fat- soluble or anti-rachitic factor, whatever that may be. Is it the comparative abundance of this factor which determines the success or failure of our resistance to the tubercle bacillus ?l The tubercle bacillus is ver y widespread. In an individual the result of any infection depends on the size of the dose and the person's resistance. Is not the quality of the resistance the more important item in tuberculosis? The medical and nursing professions must all be heavily infected, and some make a more successful resistance than others, who do not appear to he especially exp osed to infection'. The children on any dairyman 's round probably all receive, on the average, the same number of tubercle bacilli, but some resi st better than others. The cost of ordinary milk does not vary inversely with its bacillary content, and children of the richer classes, who drink more milk than others, get less tuberculosis, even of the bovine variety. Further, is not the most important period-from the anti-tuberculosis point of view-for ensuring an adequate supply of this particular subst ance the period of ante-natal and post-natal development ? This would imply the necessity of a good supply to the providers of infant nourishment, namely, the pregnant and nursing mother, and the cow. The above is the per iod during which rickets is cau sed or avoided, and the prevalences of tuberculosis and rickets are closel y connected. It is possible that by avoiding rickets, even the "minor " forms in children, we shall be doing a great deal to eradicate tuberculosis in later life. The two conditions are always more marked in poverty-stricken areas and the fat-soluble factor is always expensive. Fat containing factor A was especially hard to get during the later years of the war, and during this time there was a recrudescence of tuberculosis, though this may have been merely the abnormal reawaking of latent disease due to harder work and bad conditions. We are told that the accessory food factors are necessary in only very small quantities. This may be the CHose with the others, but is it true of the fat-soluble factor'? Very small quantities may be sufficient to permit some growth and ordinary upkeep, but large quantities seem to be required for perfect growth, especially in a rapidly growing animal. Rickets, even in the gross form, is very common, and, in its" minor .. forms, is always with us. If, as seems almost certain, dental caries is largely due to this deficiency, how few avoid it. Of the tuberculous patients examined at a tuberculosis dispensary, many have SOIDe bone malformation, and if dental caries is accepted as a sign of deficiency, practically none are free, bearing in mind that teeth are obviously intended to last a lifetime. The bronchial and alimentary tracts are constantly involved in rickets, and often are the only tissues affected in the. min~r form s, the bronchitis of children being usually curable by cod-liver 011. • " The Accessor v Food Factor s," Medical Research Committee, Special Report!', No. 38.
December, 19221
TUBERCULOSIS AS A DEFICIENCY DISEASE
109
Can one imagine a condition more favourable to the entry of either alimentary or pulmonary tuberculosis than the sodden debilitated lining membranes of those two tracts, perhaps already infected with other organisms? Is not rickets the true pre-tuberculous state? Seeing that the calcification of some permanent teeth has begun before birth, dental caries and also tuberculosis may be largely preventable antenatally. Moreover, though the mother during pregnancy and lactation, or the child may be sufficiently supplied with the substance in question, it does not follow that they will be able to absorb it. Continued vomiting during pregnancy may have the harmful effects under discussion, on the infant. In the infant, an attack of gastro-enteritis may produce an inability to absorb, lasting perhaps for some time, and this may be sufficient to induce rickets. Gastro-enteritis is frequently the reason for the early weaning of a child, and this may help to account for the frequency of rickets in bottle-fed babies, apart from the quality of the food given afterwards. In a case where, for whatever reason, the usual supply of the vitarnine is only just enough, the vomiting of the pregnant mother or the attack of gastro-enteritis in the child may be sufficient to turn the scale and precipitate a slight attack of rickets in the child. With regard to the mother, the exploded, but still prevalent idea that green vegetables cause colic in the child, may cut off a very important source of supply. The fact, too, that women's teeth give way during pregnancy, as also at puberty, implies a demand for the vitamine at these times greater than the ordinary supply, and one may point to the fact that a quiescent or mildly active pulmonary tuberculosis often increases in activity about pregnancy. The common use of barley or oatmeal water for the dilution of milk for a bottle-fed baby may cause the undesirable presence of a carbohydrate mentioned by Mellanby as a contributory cause of rickets, apart from the possible over-dilution of the milk. There have been outcries against milk as the carrying agent of the bovine forms of tuberculosis, but is it not the lack of milk, with an abundant presence of the vitamine in question, rather than the ingestion of tuberculous milk, the factor ·wh ich determines the active infection of the individual? Every doctor has seen many children in whom tuberculosis has developed in spite of great care on the part of the mothers, who may have always used sterilised milk or always boiled all the milk used in the house. It would seem that the numbers of living tubercle bacilli taken by such non-resisting children are smaller than the numbers taken by many children who do not get the disease, and this lack of resistance may be due to the destruction of the vitamines in the early days, the substances being altered by heat as in the case of lard. In these cases there is often no lack of food or air at any time. Moreover, it seems possible to make this suggestion in practically all cases of pulmonary and alimentary tuberculosis. Arguments against this suggestion naturally present themselves. There are other agents of bovine tuberculosis besides milk, for instance butter and even cheese, but as a rule, at any rate among the poorer population one child probably takes as much tuberculous butter as another, with few individual exceptions, and therefore the question of individual resistance retains its importance. Indeed, the poorer classes, who suffer
110
TUBERCLE
[December, 1922
most severely from tuberculosis, probably do afford less butter than others. Again, milk so-called pasteurised, scalded, or boiled , is often ver y imperfectl y sterilised , but the number of living tubercle bacilli taken by the individual concerned is probably not actually increased by the process and the non-resisting cases develop symptoms. There are native races which have suffered severely from epidemics of tuberculosis following the introduction of an infectious person. Here the resistance was obviously low and the cause for this is generally held to be the lack of hereditary and acquired immunity. 'Wit hout denying this, it may be suggest ed that the vitamine-content of their various diets has not yet been worked out, as far as the writer knows. In this connection it must be remembered that the vegetable oils are remarkably deficient in the" fat-soluble factor," meat is very scarce with some races, and not all fish is well supplied. Further, in all races and at all times there are people who prefer a sweet and farinaceous to a meat and fat diet. With regard to immunity the fact is that the descendants of tuberculous families, who should have a high hereditary and acquired immunity, are very liable to develop symptoms. Without doubt, increased liability to repeated infection pla ys a very imp ortant part in this process , but is it sufficient? Sometimes the secondarily infected patient dies before the primary one, e.g., a mother with .. chronic bronchitis " infects her son, who dies of tuberculosis while the mother still lives. In this case, the son cannot have It larger infection than the original source of his disease, but his resistance is lower, in spite of the increased immunity he ought to have. The bacilli may have become more virulent after passage through another host, but that is not proved. The different immunities in various animals present some interesting problems. Why do not rabbits suffer severely from tuberculosis in the wild state, as they are very susceptible? They must at times be crowded together, but they can then always obtain adequate supplies of green food, rich in the fat soluble factor. Why are sheep immune from tuberculosis while pigs and cows suffer ? Sheep are often more crowded than cows or pigs but ha ve more natural food than cows, while pigs take considerable quantities of milk from which the fat-soluble factor has been removed. Do the cattle grazing in a semi-wild state abroad suffer from tuberculosis '1 One may here ask-will the modern extensive use of artificial cake for our cattle be beneficial to us or the reverse ? The amount of sterilised food taken in the last half century has increased very much. people eating far more tinned food than formerly and tuberculosis has not increased but decreased. At the same time it has not decreased as rapidly as was hoped and expected. In this CODn ection lllay be mentioned the fishermen of Norway. In the days of short journeys in open boats with much physical labour tuberculosis was rare. With the advent of the steamer, longer journeys and closed cabins, tuberculosis increased, largely owing possibly to those conditions; but that period also saw the wide introduction of preserved milk and other foods. Is this merely a coincidence ? The fact that tuberculosis is still so prevalent, in spite of its general decrease, suggests that someth ing further is required in addition t? the extremely valuable work already being done. There can be no desire to minimise this work and it is a pity that some efforts, such as the by-laws
December, 19:12 J
SANATORIUM TREATMENT
111
against spitting in railway carriages, are not more enforced by public opinion. These efforts, however, largely aim at the reduction of the infecting dose, prophylactic vaccination, even if of value, not being widely practised. It is suggested that future generations might be better protected through increasing individual resistance by an abundant supply of the "fatsoluble" factor to the developing child, before and after birth. This raises the important question of the milk supply, which is receiving considerable attention and, one may add, that of the encouragement of allotment workers. Should not our efforts be directed to the cleansing of our milk production plant and the improvement of the feeding of our cattle rather than to the tuberculin-testing of our herds? The production of milk, clean enough for young children and mothers to drink unsterilised as a general rule, will certainly be a slow and difficult process, but the eradication of tuberculin-reacting cows will be more so and more costly; moreover the latter course may have the bad effect of making milk scarcer and dearer. As things still are, one has to choose between sterilised or dried milk, with its probable lack of vitamines-even if some of these can be otherwise supplied-and unsterilised milk, with, too frequently, consequent gastro-enteritis. It may at present be the lesser evil, but will the increased use of sterilised milk and other patent infant foods, lacking apparently the fat-soluble or anti-rachitic factor, prevent a fall in the tuberculosis rate of later generations? There seems to be considerable evidence pointing to. this possibility and the question is worthy of serious consideration. ADDENDUM. Published work, only seen by the writer after this paper was written, has confirmed the suggestion that attention should be directed to the effect of various foodstuffs on the vitamine content of cow's milk. DUHATION OF SANATORIUM TREA'l'MENT. By RONALD CAMPBELL MACFIE, M.A., M.B., C.M., LL.D. ONE of the problems to be faced in the treatment of patients at private sanatoriums, is the matter of length of sojourn. When a patient arrives at a sanatorium, one of his first and most anxious questions is: "How long shall I have to stay?" To give a categorical answer to such a question is almost impossible. No specialist can say at first sight ~ow qui~kly a patient will respond to treatment, or at what date the disease WIll be arrested or cured; and if the doctor confess that he is no prophet he is liable to be considered a fool. Even when a fairly definite prognosis might be given there are difficulties in giving it. If the doctor knows it is going to be " a long job," and suggests that treatment must be continued for a year or two, he will probably lose the patient, or the patient will lose heart. H on the other hand, in order to cheat the patient, he intentionally minimises the time requisite, he lays himself open later to a charge of wrong prognosis, and sow~ seeds of re~rimination and. disappoi~t~en~. The best thing he can do lD most cases IS to refuse to gIve an oplDJOn, If he can persuade the patient and his friends to accept a refusal. The problem is further complicated by the fact that a patient's private doctor often persuades him to enter a sanatorium by a fraudulent promise